When assessing the fetal heart rate (FHR) of a woman at 30 weeks of gestation, the nurse counts a rate of 82 beats/min. Initially the nurse should:
A. recognize that the rate is within normal limits and record it.
B. assess the woman's radial pulse.
C. notify the physician.
D. allow the woman t...
When assessing the fetal heart rate (FHR) of a woman at 30 weeks of gestation, the nurse
counts a rate of 82 beats/min. Initially the nurse should:
A. recognize that the rate is within normal limits and record it.
B. assess the woman's radial pulse.
C. notify the physician.
D. allow the woman to hear the heartbeat. - ANS B. assess the woman's radial pulse.
The expected fetal heart rate (FHR) is 120 to 160 beats/min. The nurse may have inadvertently
counted the uterine souffle, the beat-like sound of blood flowing through the uterine blood
vessels, which corresponds to the mother's heartbeat. The physician should be notified if the
FHR is confirmed to be 82 beats/min. Allow the woman to hear the heartbeat as soon as a full
assessment is made.
During a client's physical examination, the nurse notes that the lower uterine segment is soft on
palpation. The nurse would document this finding as:
A. Hegar sign.
B. McDonald sign.
C. Chadwick sign.
D. Goodell sign. - ANS A. Hegar sign.
At approximately 6 weeks of gestation, softening and compressibility of the lower uterine
segment occur; this is called the Hegar sign. The McDonald sign indicates a fast-food
restaurant. The Chadwick sign is a blue-violet cervix caused by increased vascularity; this
occurs around the fourth week of gestation. Softening of the cervical tip is called the Goodell
sign, which may be observed around the sixth week of pregnancy.
A nurse teaches a pregnant woman about the presumptive, probable, and positive signs of
pregnancy. The woman demonstrates an understanding of the nurse's instructions if she states
that a positive sign of pregnancy is:
A. a positive pregnancy test.
B. fetal movement palpated by the nurse-midwife.
C. Braxton Hicks contractions.
D. quickening. - ANS B. fetal movement palpated by the nurse-midwife.
A positive pregnancy test is a probable sign of pregnancy. Positive signs of pregnancy are those
that are attributed to the presence of a fetus, such as hearing the fetal heartbeat or palpating
fetal movement. Braxton Hicks contractions are a probable sign of pregnancy. Quickening is a
presumptive sign of pregnancy.
,Cardiovascular system changes occur during pregnancy. Which finding would be considered
normal for a woman in her second trimester?
A. Less audible heart sounds (S1, S2)
B. Increased pulse rate
C. Increased blood pressure
D. Decreased red blood cell (RBC) production - ANS B. Increased pulse rate
Splitting of S1 and S2 is more audible. Between 14 and 20 weeks of gestation, the pulse
increases about 10 to 15 beats/min, which persists to term. In the first-trimester blood pressure
usually remains the same as the prepregnancy level, but it gradually decreases up to about 20
weeks of gestation. During the second trimester both the systolic and diastolic pressures
decrease by about 5 to 10 mm Hg. Production of RBCs accelerates during pregnancy.
In order to reassure and educate pregnant clients about changes in their blood pressure,
maternity nurses should be aware that:
A. a blood pressure cuff that is too small produces a reading that is too low; a cuff that is too
large produces a reading that is too high.
B. shifting the client's position and changing from arm to arm for different measurements
produces the most accurate composite blood pressure reading at each visit.
C. the systolic blood pressure increases slightly as pregnancy advances; the diastolic pressure
remains constant.
D. compression of the iliac veins and inferior vena cava by the uterus contributes to
hemorrhoids in the latter stage of term pregnancy. - ANS D. compression of the iliac veins
and inferior vena cava by the uterus contributes to hemorrhoids in the latter stage of term
pregnancy.
The tightness of a cuff that is too small produces a reading that is too high; similarly, the
looseness of a cuff that is too large results in a reading that is too low. Because maternal
positioning affects readings, blood pressure measurements should be obtained in the same arm
and with the woman in the same position. The systolic blood pressure generally remains
constant but may decline slightly as pregnancy advances. The diastolic blood pressure first
drops and then gradually increases. This compression also leads to varicose veins in the legs
and vulva.
If exhibited by a pregnant woman, what represents a positive sign of pregnancy?
A. Morning sickness
B. Quickening
C. Positive pregnancy test
D. Fetal heartbeat auscultated with Doppler/fetoscope - ANS D. Fetal heartbeat
auscultated with Doppler/fetoscope
Morning sickness and quickening, along with amenorrhea and breast tenderness, are
presumptive signs of pregnancy; subjective findings are suggestive but not diagnostic of
pregnancy. Other probable signs include changes in integument, enlargement of the uterus, and
Chadwick sign. A positive pregnancy test is still considered to be a probable sign of pregnancy
(objective findings are more suggestive but not yet diagnostic of pregnancy) since error can
occur in performing the test or in rare cases human chorionic gonadotropin (hCG) may be
, detected in the urine of nonpregnant women. Chances of error are less likely to occur today
since pregnancy tests used are easy to perform and are very sensitive to the presence of the
hCG associated with pregnancy. Detection of a fetal heartbeat, palpation of fetal movements
and parts by an examiner, and detection of an embryo/fetus with sonographic examination
would be positive signs diagnostic of pregnancy.
A nurse is reviewing information related to home pregnancy tests so as to prepare for a patient
teaching session. Which statement by the patient indicates that additional instruction is needed
following the teaching session?
A. The patient states that she will follow directions as listed on the testing package.
B. The patient indicates that a positive result will be seen if there is a color change on the
applicator.
C. The patient states there is no need for concern as home pregnancy test results are 100%
correct.
D. The patient can perform the test without any assistance in the home setting - ANS C.
The patient states there is no need for concern as home pregnancy test results are 100%
correct.
Home pregnancy testing while reliable does not provide 100% correct results. There are other
variables such as medication history as well as timing of specimen, collection and interpretation
that may lead to inaccurate results. Following directions, noting a color change as a positive
result and being able to perform the test without any assistance in the home setting all indicate
that the patient has an understanding of the process.
A woman is 6 weeks pregnant. She has had a previous spontaneous abortion at 14 weeks of
gestation and a pregnancy that ended at 38 weeks with the birth of a stillborn girl. What is her
gravidity and parity using the GTPAL system? - ANS 31010
Using the GPTAL system, this woman's gravidity and parity information is calculated as
follows:G: Total number of times the woman has been pregnant (she is pregnant for the third
time) T: Number of pregnancies carried to term (she has one stillborn) P: Number of
pregnancies that resulted in a preterm birth (she has none) A: Abortions or miscarriages before
the period of viability (she has had one) L: Number of children born who are currently living (she
has no living children)
Which hematocrit (Hct) and hemoglobin (Hgb) results represent(s) the lowest acceptable values
for a woman in the third-trimester of pregnancy?
A. 38% Hct; 14 g/dL Hgb
B. 35% Hct; 13 g/dL Hgb
C. 33% Hct; 11 g/dL Hgb
D. 32% Hct; 10.5 g/dL Hgb - ANS C. 33% Hct; 11 g/dL Hgb
This is within normal limits in the nonpregnant woman. This is within normal limits for a
nonpregnant woman. Represents the lowest acceptable value during the first and the third
trimesters. This represents the lowest acceptable value for the second trimester when the
hemodilution effect of blood volume expansion is at its peak.
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